Dyspnea and pain frequently co-occur among Medicare managed care recipients

Pain and Heart Failure During Transport by Emergency Medical Services and Its Associated Outcomes: Hospitalization, Mortality, and Length of Stay

BACKGROUND

Over 22% of patients with heart failure (HF) are transported by emergency medical services (EMSs) for a primary complaint of pain. The relationship between a primary complaint of pain on hospitalization status, mortality, or length of stay following transport by EMS is understudied.

OBJECTIVES

The objective of this study was to determine whether a primary complaint of pain during EMS transport predicted hospitalization status, mortality, or inpatient length of stay.

METHODS

In this retrospective longitudinal cohort study, data were analyzed from electronic health records of 3539 patients with HF. Descriptive statistics and multivariate logistic and linear regression analyses were used to achieve study objectives.

RESULTS

Demographics were mean age 64.83 years (standard deviation [SD] = 14.58); gender 57.3% women, 42.7% men; self-reported race 56.2% black, 43.2% white, and 0.7% other. Of 3539 patients, 2346 (66.3%) were hospitalized, 149 (4.2%) died, and the mean length of stay was 6.02 (SD = 7.55) days. A primary complaint of pain did not predict increased odds of in-hospital mortality but did predict 39% lower odds of hospitalization (p < .001), and 26.7% shorter length of stay (p < .001). Chest pain predicted 49% lower odds of hospitalization (p < .001) and 34.1% (p < .001) shorter length of stay, whereas generalized pain predicted 45% lower odds of hospitalization (p = .044) following post-hoc analysis.

CONCLUSIONS

A primary complaint of chest pain predicted lower odds of hospitalization and shorter length of stay, possibly due to established treatment regimens. Additional research is needed to examine chronic pain rather than a primary complaint of pain.

Common and distinct risk factors that influence more severe and distressing shortness of breath profiles in oncology outpatients

BACKGROUND

Shortness of breath occurs in 10%-70% of oncology patients. Very little is known about interindividual variability in its severity and distress and associated risk factors. Using latent profile analyses (LPAs), purpose was to identify subgroups of patients with distinct severity and distress profiles for shortness of breath as single symptom dimensions. In addition, a joint LPA was done using patients' severity AND distress ratings. For each of the three LPAs, differences among the shortness of breath classes in demographic, clinical, symptom, stress, and resilience characteristics were evaluated.

METHODS

Patients completed ratings of severity and distress from shortness of breath a total of six times over two cycles of chemotherapy. All of the other measures were completed at enrollment (i.e., prior to the second or third cycle of chemotherapy). Separate LPAs were done using ratings of severity and distress, as well as a joint analysis using severity AND distress ratings. Differences among the latent classes were evaluated using parametric and nonparametric tests.

RESULTS

For severity, two classes were identified (Slight to Moderate [91.6%] and Moderate to Severe [8.4%]). For distress, two classes were identified (A Little Bit to Somewhat [83.9%] and Somewhat to Quite a Bit [16.1%]). For the joint LPA, two classes were identified (Lower Severity and Distress [79.9%] and Higher Severity and Distress [20.1%]). While distinct risk factors were associated with each of the LPAs, across the three LPAs, the common risk factors associated with membership in the worse class included: a past or current history of smoking, poorer functional status, and higher comorbidity burden. In addition, these patients had a higher symptom burden and higher levels of cancer-specific stress.

CONCLUSIONS

Clinicians can use the information provided in this study to identify high-risk patients and develop individualized interventions.

Is Pulmonary Involvement a Distinct Phenotype of Post-COVID-19?

(1) Background: COVID-19 infection often provokes symptoms lasting many months: most commonly fatigue, dyspnea, myalgia and mental distress symptoms. In this study, we searched for clinical features of post-COVID-19 condition (PCC) and differences between patients with and without pulmonary involvement. (2) Methods: A total of 282 patients with a mean age of 57 years (SD +/- 12 years) underwent assessment up to 12 weeks after COVID-19 recovery. The course of acute disease, past medical history and clinical symptoms were gathered; pulmonary function tests were performed; radiographic studies were assessed and follow-up examinations were conducted. Patients with and without detectable pulmonary lesions were divided into separate groups. (3) Results: Patients within the pulmonary group were more often older (59 vs. 51 y.o.; p < 0.001) males (p = 0.002) that underwent COVID-19-related hospitalization (p < 0.001) and were either ex- or active smokers with the median of 20 pack-years. We also managed to find correlations with hypertension (p = 0.01), liver failure (p = 0.03), clinical symptoms such as dyspnea (p < 0.001), myalgia (p = 0.04), headache (p = 0.009), sleeplessness (p = 0.046), pulmonary function tests (such as FVC, TLCO, RV and TLC; p < 0.001) and several basic laboratory tests (D-dimer, cardiac troponin, WBC, creatinine and others). (4) Conclusions: Our results indicate that initial pulmonary involvement alters the PCC, and it can be used to individualize clinical approaches.

Higher Lifetime Stress and Symptom Burden Contribute to the Occurrence of Shortness of Breath

OBJECTIVES

Among four classes of patients with distinct shortness of breath profiles, evaluate for differences in levels of global, cancer-specific, and cumulative life stress, as well as resilience; evaluate for differences in the occurrence rates for various stressful life events, and evaluate for differences in the severity of common co-occurring symptoms.

DATA SOURCES

Outpatients (N = 1338) completed questionnaires six times over two cycles of chemotherapy. The occurrence of shortness of breath was assessed using the Memorial Symptom Assessment Scale. Latent class analysis was used to identify subgroups of patients with distinct shortness of breath profiles. Differences among the classes were evaluated using parametric and nonparametric tests.

CONCLUSION

Shortness of breath classes were labeled based on their distinct occurrence trajectories: None (70.5%), Decreasing (8.2%), Increasing (7.8%), and High (13.5%). Compared to None class, Decreasing and High classes had higher global and cancer-specific stress scores. The High class reported higher occurrence rates for several adverse childhood experiences. Compared to None class, Decreasing and High classes had higher depression, anxiety, and morning fatigue scores and lower morning energy and cognitive function scores.

IMPLICATIONS FOR NURSING PRACTICE

Given the additive or synergistic relationships between stress, co-occurring symptoms, and shortness of breath, multimodal interventions that include stress management, exercise training, and/or symptom management may decrease shortness of breath in oncology patients.

Impact of Indoor Air Quality and Breathing on Back and Neck Pain: A Systematic Review

Back pain and neck pain are important public health concerns and are among the most common and disabling conditions globally. However, the relationships among indoor air quality (IAQ), breathing parameters (pulmonary function, respiratory disorders), and back pain and neck pain have not been adequately assessed. The purpose of this study was to systematically review the literature about the impact of IAQ and breathing parameters on back pain and neck pain (PROSPERO ID: CRD42022380515). CINAHL, EMBASE, PEDRo, and PubMed databases were searched through January 19, 2023. Inclusion criteria for study eligibility were observational studies (except case reports) or randomized controlled trials (RCTs), published in peer-reviewed journals in the English language, human research, original research, examined the relationships between IAQ, or breathing parameters with back pain or neck pain. Review procedures were conducted and reported according to PRISMA recommendations. Empirical evidence statements were developed for observational studies, and grades of evidence statements were developed for RCTs. Sixty-seven eligible studies were found (54 observational studies and 13 RCTs) that enrolled 345,832 participants. None of the studies assessed the combined impact of IAQ and breathing parameters on back pain or neck pain. No level 1 studies were found, which precludes making strong statements about causality and strong recommendations about the efficacy of IAQ and breathing exercise interventions for reducing pain and disability related to back pain and neck pain. Evidence indicates that poor IAQ and respiratory disorders are related to an increased risk of back pain and neck pain. Conflicting evidence exists about the association between pulmonary function with back pain and neck pain. Evidence for breathing exercise interventions was mixed with numerous limitations. This review provides preliminary evidence on the relationships of IAQ and breathing parameters with back pain and neck pain, which can be used to guide future research and clinical implementation efforts. Assuming positive findings in subsequent research, a wide range of stakeholders involved with this complex human-building-environment interface can be equipped to address IAQ and breathing parameters, along with other established risk factors to help those suffering from back pain and neck pain.

Distinct Shortness of Breath Profiles in Oncology Outpatients Undergoing Chemotherapy

CONTEXT

Shortness of breath is a distressing symptom that occurs in 10% to 70% of oncology patients. Despite this broad range in its occurrence, little is known about inter-individual variability in shortness of breath and associated risk factors among patients receiving chemotherapy.

OBJECTIVES

Identify subgroups of patients with distinct shortness of breath profiles; evaluate for differences among these subgroups in demographic and clinical characteristics; evaluate for differences among symptom dimensions of shortness of breath, and evaluate for differences in quality of life outcomes.

METHODS

Outpatients (n=1338) completed questionnaires six times over two chemotherapy cycles. Occurrence of shortness of breath was assessed using the Memorial Symptom Assessment Scale. Latent class analysis was used to identify subgroups of patients with distinct shortness of breath profiles.

RESULTS

Four distinct shortness of breath profiles were identified (None [70.5%], Decreasing [8.2%], Increasing [7.8%], High [13.5%]). Risk factors for membership in High class included: history of smoking, self-reported diagnosis of lung disease, having lung cancer, and receipt of a higher number of cancer treatments. Compared to the None class, High class reported poorer physical, psychological, and social functioning.

CONCLUSIONS

Almost 14% of patients with heterogeneous types of cancer receiving chemotherapy had persistently high occurrence rates of shortness of breath for almost two months. In addition, compared to the Decreasing and Increasing classes, the High class' episodes of shortness of breath were more frequent and more severe. Clinicians need to assess all oncology patients for shortness of breath and provide targeted interventions.

The effect of trait self-control on dyspnoea and tolerance to a CO2 rebreathing challenge in healthy males and females

BACKGROUND

High trait self-control is associated with greater tolerance of unpleasant sensations including effort and pain. Dyspnoea and pain have several commonalities and this study aimed to investigate for the first time whether trait self-control influences responses to a hypercapnic rebreathing challenge designed to induce dyspnoea. As sex also influences tolerance to dyspnoea, we also sought to investigate whether this moderated the role of trait self-control.

METHODS

Participants (n = 65, 32 females) scoring high or low for trait self-control, performed a standardised rebreathing challenge, in which inspired carbon dioxide (CO₂) gradually increased over a period of 6 min or until an intolerable level of dyspnoea. Air hunger (AH) intensity - a distinctive quality of dyspnoea, was measured every 30 s. The multidimensional dyspnoea profile (MDP) was completed after the rebreathing challenge for a more complete overview of breathing discomfort.

RESULTS

Males high in trait self-control (SCHIGH) (302 ± 42 s), tolerated the rebreathing challenge for longer than males low in self-control (SCLOW) (252 ± 66 s, P = 0.021), experienced slower increases in AH intensity during the rebreathing challenge (0.03 ± 0.01 cm^.s ^- 1 vs. 0.04 ± 0.01 cm^.s ^- 1,P = 0.045) and reported lower perceived mental effort on the MDP (4.94 ± 2.46 vs. 7.06 ± 1.60, P = 0.007). There was no difference between SCHIGH and SCLOW females for challenge duration. However, SCHIGH females (9.29 ± 0.66 cm) reported greater air hunger at the end of the challenge than SCLOW females (7.75 ± 1.75 cm, P = 0.003). It is possible that SCLOW females were unwilling to tolerate the same perceptual intensity of AH as the SCHIGH females.

CONCLUSIONS

These results indicate that individuals high in trait self-control are more tolerant of dyspnoea during a CO₂ rebreathing challenge than low self-control individuals. Tolerance of the stimulus was moderated by the sex of the participant, presenting an interesting opportunity for future research.

Potential Explanatory Factors for the Concurrent Experience of Dyspnea and Pain in Patients with COPD

Previous research has identified unexpectedly strong associations between dyspnea and pain, but the reasons remain unclear. Ascertaining the underlying biological and psychological mechanisms might enhance the understanding of the experience of both conditions, and suggest novel treatments. We sought to elucidate whether demographic factors, disease severity, psychological symptoms and biomarkers might account for the association between pain and dyspnea in individuals with COPD. We analyzed data from 301 patients with COPD who were followed in a prospective longitudinal observational study over 2 years. Measures included self-reported dyspnea and pain, pulmonary function tests, serum levels of inflammatory cytokines, measures of physical deconditioning, and scales for depression and anxiety. Analyses involved cross-sectional and longitudinal linear regression models. Pain and dyspnea were strongly correlated cross-sectionally (r = 0.77, 95% CI 0.72-0.82) and simultaneously across time (r = 0.42, 95% CI 0.28-0.56). Accounting for any of the other health factors only slightly mitigated the associations. Symptoms of pain and dyspnea thus may be fundamentally linked in COPD, rather than being mediated by common biological, psychological, or functional factors. From the patient's perspective, pain and dyspnea may be part of the same essential experience. It is possible that treatments for one condition would improve the other.

Characterizing Pain Leading to Emergency Medical Services Activation in Heart Failure

BACKGROUND

Pain is a common but understudied symptom among patients with heart failure (HF) transported by emergency medical services (EMS). The aims were to determine explanatory factors of a primary complaint of pain and pain severity, and characterize pain among patients with HF transported by EMS.

METHODS

Data from electronic health records of patients with HF transported by EMS within a midwestern United States county from 2009 to 2017 were analyzed. Descriptive statistics, χ 2 , analysis of variance, and logistic and multiple linear regression analyses were used.

RESULTS

The sample (N = 4663) was predominantly women (58.1%) with self-reported race as Black (57.7%). The mean age was 64.2 ± 14.3 years. Pain was the primary complaint in 22.2% of the sample, with an average pain score of 6.8 ± 3.1 out of 10. The most common pain complaint was chest pain (68.1%). Factors associated with a primary pain complaint were younger age (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.96-0.97), history of myocardial infarction (OR, 1.96; 95% CI, 1.55-2.49), and absence of shortness of breath (OR, 0.67; 95% CI, 0.58-0.77). Factors associated with higher pain severity were younger age ( b = -0.05, SE = 0.013), being a woman ( b = 1.17, SE = 0.357), and White race ( b = -1.11, SE = 0.349).

CONCLUSIONS

Clinical and demographic factors need consideration in understanding pain in HF during EMS transport. Additional research is needed to examine these factors to improve pain management and reduce transports due to pain.

Common and distinct characteristics associated with self-reported functional status in older patients with cancer receiving chemotherapy

PURPOSE

To evaluate for inter-individual differences in two subjective measures of functional status in older patients (n = 112), as well as to determine which demographic, clinical, and symptom characteristics, and levels of cognitive function, were associated with initial levels and with the trajectory of the two measures.

METHODS

Functional status was assessed using self-report measures of physical function (PF) and role function (RF) from the European Organization for Research and Treatment of Cancer Core Quality-of-Life Questionnaire at the initiation of chemotherapy and at 1, 3, 6, 9, and 12 months after its initiation. Hierarchical linear modeling was used to assess inter-individual differences in and characteristics associated with initial levels and changes in PF and RF.

RESULTS

Characteristics associated with decreases in PF at the initiation of chemotherapy were higher numbers of comorbidities and higher depression, pain, and dyspnea scores. For initial levels of poorer RF, lower Karnofsky Performance Status scores and higher pain and fatigue scores were the associated characteristics. Characteristic associated with worse trajectories of PF was not having had surgery. For RF, worse trajectories were associated with lower cognitive function and higher RF at enrollment. Characteristic associated with both lower initial levels and improved trajectories of PF was having lower performance status at enrollment.

CONCLUSIONS

Older patients undergoing chemotherapy experience reduced functional performance. Characteristics associated with decrements in PF and RF need to be assessed and interventions implemented to maintain and increase functional status in older oncology patients.

Brief Report: Association Between Pain, Pulmonary Function, and Respiratory Symptoms in People With HIV

BACKGROUND

People with HIV (PWH) experience chronic pain and respiratory symptoms, which are closely related in the general population. Pain may affect the impaired pulmonary function seen in PWH beyond its association with HIV alone. Our objective was to investigate the relationship of pain severity to pulmonary function, respiratory symptoms, and sleep disturbance in PWH.

SETTING

Study sites included the University of Pittsburgh, University of California San Francisco, and University of Washington.

METHODS

Pain, dyspnea, and sleep were assessed using the Brief Chronic Pain Questionnaire, St. George's Respiratory Questionnaire, and Pittsburgh Sleep Quality Index. Participants performed prebronchodilator and postbronchodilator spirometry and 6-minute walk test. Associations between pain severity, lung function, dyspnea, and sleep were assessed with bivariate and multiple quantile regression analysis adjusted for age, sex, race, body mass index, and smoking status.

RESULTS

Of 159 PWH, the median age was 56 years with 30.8% women. Two-thirds experienced pain in the past week, with 40.3% reporting chronic pain. Pain severity was higher with female sex (P = 0.038), non-White race (P = 0.005), current smoking (P = 0.003), and lower CD4+ count (P = 0.035). In adjusted analysis, higher pain severity was correlated with reduced postbronchodilator forced expiratory volume in 1 second %predicted (P = 0.008), reduced postbronchodilator forced vital capacity %predicted (P = 0.019), and chronic obstructive pulmonary disease (P = 0.032). Greater pain severity was strongly associated with a higher St. George's Respiratory Questionnaire score (P < 0.001) and sleep disturbance (P < 0.001).

CONCLUSIONS

In PWH, pain is common and associated with airflow obstruction, dyspnea, and sleep disturbance. Future studies assessing pain severity and pulmonary function over time could clarify the direction of this association and the impact on quality of life.

Prevalence and Risk Factors of Breathlessness Across Canada: A National Retrospective Cohort Study in Home Care and Nursing Home Populations

CONTEXT

Breathlessness is a symptom associated with poor clinical outcomes and prognosis. Little is known about its long-term trends and associations with social factors including decline in social activities and caregiver distress.

OBJECTIVES

To describe factors associated with the prevalence of clinician-reported breathlessness across Canada among cohorts receiving home care or nursing home care.

METHODS

A retrospective observational cohort study of cross-sectional intake assessment data from Canadian interRAI Home Care and Nursing Home data sets. In each data set, we examined covariates associated with the presence of clinician-reported breathlessness using multivariate regression.

RESULTS

Between 2007 and 2018, we identified 1,317,117 and 469,709 individuals from the home care and nursing home data sets, respectively. Over two-thirds were aged >75 and over 60% were women. Breathlessness was present at intake in 26.0% of the home care and 8.2% of the nursing home cohorts. Between 2007 and 2018, prevalence of breathlessness increased by 10% for the home care cohort, while remaining relatively constant in nursing homes. Covariates associated with increased odds of having clinician-reported breathlessness at intake in both cohorts were moderate-severe impairment with activities of daily living, being male, older age, high pain scores, signs of depression, and decline in social activities. In the home care cohort, the presence of breathlessness was associated with a greater odds of caregiver distress (odds ratio = 1.19, 95% CI: 1.18-1.20).

CONCLUSION

The prevalence of clinician-reported breathlessness is higher in home care than in nursing home populations, the former having risen by 10% over the decade. Prevalence of breathlessness is associated with decline in social activities and caregiver distress. Enhanced supports may be required to meet increasing patient need in the community.

Co-occurrence of pain and dyspnea in Veterans with COPD: Relationship to functional status and a pilot study of neural correlates using structural and functional magnetic resonance imaging

Persons with COPD experience co-occurring dyspnea and pain. Little is known about the relationship between symptom co-occurrence with physical activity (PA) and exercise. Novel diagnostic tools are needed for accurate symptom discrimination. In this secondary analysis, we examined relationships between baseline assessments of pain, dyspnea, objectively measured PA, and exercise capacity in persons with COPD who previously enrolled in three PA studies. Pain was assessed with the bodily pain domain of the Veterans RAND-36 (VR-36), and dyspnea with the modified Medical Research Council (mMRC) scale. Average daily step count was assessed with the Omron HJ-720ITC or FitBit Zip pedometer, and exercise capacity with 6-minute walk test (6MWT). We also conducted a pilot neuroimaging study. Neuroimaging data were acquired on a Siemens 3-Tesla Magnetom Prismafit whole-body scanner. Analysis of variance assessed trends in daily step count and 6MWT distance across categories of co-occurring pain and dyspnea. General linear models examined relationships between cortical thickness and resting state functional connectivity (fc) with symptoms and functional status. In 373 Veterans, 98% were male with mean age 70.5± 8.3 years and FEV1% predicted 59 ± 21%. Compared to those with no co-occurrence of pain and dyspnea, those with co-occurrence walked 1,291-1,444 fewer steps per day and had an 80-85 m lower 6MWT distance. Ten males participated in the pilot neuroimaging study. Predominant findings were that lower cortical thickness and greater fc were associated with higher pain and dyspnea, p<0.05. Greater cortical thickness and lower fc were associated with higher daily step count and 6MWT distance, p<0.05. Regional patterns of associations differed for pain and dyspnea, suggesting that cortical thickness and fc may discriminate symptoms. Co-occurring dyspnea and pain in COPD are associated with significant reductions in PA and exercise capacity. It may be feasible for neuroimaging markers to discriminate between pain and dyspnea.

The breathing brain: The potential of neural oscillations for the understanding of respiratory perception in health and disease

Dyspnea or breathlessness is a symptom occurring in multiple acute and chronic illnesses, however, the understanding of the neural mechanisms underlying its subjective experience is limited. In this topical review, we propose neural oscillatory dynamics and cross-frequency coupling as viable candidates for a neural mechanism underlying respiratory perception, and a technique warranting more attention in respiration research. With the evidence for the potential of neural oscillations in the study of normal and disordered breathing coming from disparate research fields with a limited history of interdisciplinary collaboration, the main objective of the review was to converge the existing research and suggest future directions. The existing findings show that distinct limbic and cortical activations, as measured by hemodynamic responses, underlie dyspnea, however, the time-scale of these activations is not well understood. The recent findings of oscillatory neural activity coupled with the respiratory rhythm could provide the solution to this problem, however, more research with a focus on dyspnea is needed. We also touch on the findings of distinct spectral patterns underlying the changes in breathing due to experimental manipulations, meditation and disease. Subsequently, we suggest general research directions and specific research designs to supplement the current knowledge using neural oscillation techniques. We argue for the benefits of interdisciplinary collaboration and the converging of neuroimaging and behavioral methods to best explain the emergence of the subjective and aversive individual experience of dyspnea.

Cross-modal relationships of neural gating with the subjective perception of respiratory and somatosensory sensations

Neural gating is a phenomenon whereby the response to a stimulus in the electroencephalogram (EEG) is attenuated when preceded by an identical stimulus. Attenuation of paired auditory clicks has repeatedly been shown to be affected in mental disorders, for example, schizophrenia. Neural gating has also been measured for respiratory and somatosensory sensations, however the attenuation of bodily relevant stimuli has not yet been systematically related to the subjective perception of bodily sensations. This research direction is potentially relevant to explaining disease trajectories in psychosomatic conditions characterized by chronic breathlessness and/or pain. In the present study, we recorded high-density EEG from 85 healthy young adults while they experienced brief paired respiratory occlusions and brief paired electrocutaneous stimulation of the wrist. The event-related potential N1 was measured centro-laterally in response to the second relative to the first stimulus to quantify neural gating in both sensory domains. Participants experienced resistive loaded breaths and electrocutaneous stimuli of various intensities, rated their perceived intensity and unpleasantness, and performed magnitude estimation. Relationships of respiratory and somatosensory neural gating to the subjective intensity and unpleasantness of sensations, as well as the ability to discriminate sensations of varying intensities, were investigated intra-modally and cross-modally. We report significant relationships of the somatosensory neural gating to perceived intensity and unpleasantness of respiratory and somatosensory sensations, with the stronger neural gating relating to a stronger subjective intensity and unpleasantness. We discuss these unexpected findings through the lens of individual differences and different theoretical accounts on the origins of cortical attenuation of repetitive stimuli.

Pain in patients with chronic obstructive pulmonary disease indicated for post-acute pulmonary rehabilitation

Pain is a significant problem in stable chronic obstructive pulmonary disease (COPD) and is associated with other symptoms, worse health status and lower functional status. Not much is known about pain in unstable disease. The primary aim of the present study is to investigate prevalence, characteristics and relationships of pain in patients with COPD hospitalized for an acute exacerbation (AECOPD) and indicated for post-acute pulmonary rehabilitation (PR). This cross-sectional observational study included 149 patients (mean age 70.8 (±7.9) years, 49% male, mean forced expiratory volume in one second as percentage of predicted value 35.3 (±12.6)). Pain was assessed using the brief pain inventory. Functional status and health status were measured using the six-minute walking test (6MWT), the Barthel index (BI) and the clinical COPD questionnaire (CCQ), respectively. Pain was prevalent in 39.6% of all patients. Symptom burden was high, especially in patients with pain. Although we found no difference in objective measurements of functional status (6MWT, BI), patients with pain had clinically relevant lower health status (CCQ), attributed to the functional domain. Pain in patients hospitalized for AECOPD and indicated for post-acute PR is a relevant problem and needs more attention. Incorporation of standard pain assessment during exacerbations and post-acute PR is recommended.

Reliability and construct validity of a composite pain scale for rabbit (CANCRS) in a clinical environment

A composite pain scale for assessing and quantifying pain in rabbits (CANCRS) has been designed merging the Rabbit Grimace Scale (RbtGS) and a scale including clinical parameters (CPS). Construct validity and inter-rater reliability were assessed for CANCRS, for RbtGS and for CPS, in order to test their potential to detect pain in a clinical setting. Rabbits (n = 116) were either hybrids or purebreds and they were independently evaluated by two raters, who could be veterinarians (V) or veterinary medicine students (S). Score intervals determined four pain classes (No pain, Discomfort, Moderate pain and Severe pain) that matched presumptive pain classes associated with some pathological conditions. A chi-square test was used to assess the construct validity of the scales by checking how frequently scale results and presumptive pain classes matched. Sixty-nine patients were evaluated by one V and one S, whereas forty-seven rabbits were assessed by two V, in order to test inter-rater reliability. An intra-class correlation coefficient (ICC) was used to test reliability of the scales, whereas Cohen’s kappa tested inter-rater agreement for each parameter of the CANCRS. Construct validity results show that CANCRS and RbtGS efficiently reveal pain (P ≤ 0.05), while CPS does not (p > 0.05). Inter-rater reliability was very good for both CANCRS and CPS (ICC 0.88 V-V, 0.94 between V-S; ICC 0.97 V-V, 0.91 V-S) and good for RbtGS (ICC 0.77 V-V, 0.88 V-S); therefore, CPS reproducibility was better between veterinarians and students than between veterinarians. Inter-rater agreement between veterinarians and veterinary medicine students was moderate to very good for all the parameters included in the CANCRS (Cohen’s kappa >0,60). In conclusion, it is possible to state that the CANCRS has construct validity and it is a reliable tool for use in clinical practice, when coping with many rabbits with morphological differences. It is easy and fast to use and enriches the RbtGS with some clinical parameters that should be monitored during any clinical examination, allowing for capture of the multidimensional aspect of pain.

Prevalence and Characteristics of Pain in Patients of Chronic Obstructive Pulmonary Disease: A Cross-Sectional Study in China

The purposes of this study were to: (1) study the prevalence of pain in patients with mild-to-very severe chronic obstructive pulmonary disease (COPD) in China; (2) compare the differences in pain characteristics between stable COPD and acute exacerbation of COPD (AECOPD); (3) explore the clinical associations with pain in those with COPD. This cross-sectional study was conducted in China from October 24, 2017, to January 11, 2019. A face-to-face interview was conducted to collect data. The Chinese version of the brief pain inventory (BPI-C) was applied to investigate the pain characteristics in patients with COPD. Of the 901 patients in this study, 226 (25.1%) patients reported pain problems. The prevalence of pain in patients with mild to very severe COPD was 32.9%, 23.9%, 25.2%, and 23.5%, respectively (p = 0.447). According to the BPI-C results, 31.3% (31/99) of patients reported pain of AECOPD, compared to 24.3% (195/802) of stable COPD (p = 0.13). Reported pain intensity and pain interference evaluated by the BPI-C were significantly higher in AECOPD than stable COPD (p < 0.001, p < 0.05, respectively). Those with body mass index (BMI) ≥ 24kg/m² or COPD assessment test (CAT) score > 20 were significantly more likely to have pain problems than BMI < 24kg/m² (aOR = 1.568, a95IC = 1.132-2.170, p = 0.007) or CAT ≤ 20 (aOR= 1.754, a95IC = 1.213-2.536, p = 0.003). Pain was common in patients with both stable COPD and AECOPD. AECOPD patients had a significantly higher pain intensity than stable COPD. Overweight and CAT > 20 were significantly related to higher prevalence of pain.

Polypharmacy Increases Risk of Dyspnea Among Adults With Serious, Life-Limiting Diseases

BACKGROUND

Polypharmacy is associated with dyspnea in cross-sectional studies, but associations have not been determined in longitudinal analyses. Statins are commonly prescribed but their contribution to dyspnea is unknown. We determined whether polypharmacy was associated with dyspnea trajectory over time in adults with advanced illness enrolled in a statin discontinuation trial, overall, and in models stratified by statin discontinuation.

METHODS

Using data from a parallel-group unblinded pragmatic clinical trial (patients on statins ≥3 months with life expectancy of 1 month to 1 year, enrolled in the parent study between June 3, 2011, and May 2, 2013, n = 308/381 [81%]), we restricted analyses to patients with available baseline medication count and ≥1 dyspnea score. Polypharmacy was assessed by self-reported chronic medication count. Dyspnea trajectory group, our primary outcome, was determined over 24 weeks using the Edmonton Symptom Assessment System.

RESULTS

The mean age of the patients was 73.8 years (standard deviation [SD]: ±11.0) and the mean medication count was 11.6 (SD: ±5.0). We identified 3 dyspnea trajectory groups: none (n = 108), mild (n = 130), and moderate-severe (n = 70). Statins were discontinued in 51.8%, 48.5%, and 42.9% of patients, respectively. In multivariable models adjusting for age, sex, diagnosis, and statin discontinuation, each additional medication was associated with 8% (odds ratio [OR] = 1.08 [1.01-1.14]) and 16% (OR = 1.16 [1.08-1.25]) increased risk for mild and moderate-severe dyspnea, respectively. In stratified models, polypharmacy was associated with dyspnea in the statin continuation group only (mild OR = 1.12 [1.01-1.24], moderate-severe OR = 1.24 [1.11-1.39]) versus statin discontinuation (mild OR = 1.03 [0.95-1.12], and moderate-severe OR = 1.09 [0.98-1.22]).

CONCLUSION

Polypharmacy was strongly associated with dyspnea. Prospective interventions to decrease polypharmacy may impact dyspnea symptoms, especially for statins.

Neighborhood air pollution and household environmental health as it relates to respiratory health and healthcare utilization among elderly persons with asthma

Objective: The study investigated the associations between fine particulate matter (PM_2.5; <2.5 μm in diameter), indoor environment, pulmonary function, and healthcare utilization in a vulnerable group of elderly persons with asthma. We hypothesized that environmental conditions were associated with adverse pulmonary health outcomes. Methods: The study involved elderly (n = 76; mean age 64.6 years; 48 women) vulnerable persons in Detroit, Michigan, USA, with physician-diagnosed asthma. Exposure variables included measured outdoor PM_2.5, self-rated outdoor and household environmental pollutants. Outcome variables were self-rated and measured pulmonary function, and asthma-related healthcare utilization. Results: Mean ambient PM_2.5 concentrations during the study was 14.14 ± (S.D. 6.36) µg/m³ during the summer and 14.20 (6.33) during the winter (p = 0.95). In multiple regression analyses, adjusting for age and gender, mean 6-month concentration of PM_2.5 was related to shortness of breath (SHOB; standardized β = 0.26, p = 0.02) and inversely with self-rated respiratory health (SRRH; β = 0.28, p = 0.02). However, PM_2.5 did not predict lung function (FEV₁% predicted and FEV₁/FVC). However, PM_2.5 was related to use of asthma controller drugs (β = 0.38, p = 0.001). Participants' air pollution ratings predicted total healthcare utilization (β = 0.33, p = 0.01). Conclusions: In elderly persons with asthma, living near heavy industry and busy highways, objective and perceived environmental pollution relate to participants' respiratory health and healthcare utilization. Importantly, air pollution might increase use of asthma controller drugs containing corticosteroids with implication for elderly persons' risk to develop osteoporosis and cardiovascular disease.

Self-Management of Cardiac Pain in Women: A Meta-Summary of the Qualitative Literature

Symptom recognition and self-management is instrumental in reducing the number of deaths related to coronary artery disease (CAD) in women. The purpose of this study was to synthesize qualitative research evidence on the self-management of cardiac pain and associated symptoms in women. Seven databases were systematically searched, and the concepts of the Individual and Family Self-Management Theory were used as the framework for data extraction and analysis. Search strategies yielded 22,402 citations, from which 35 qualitative studies were included in a final meta-summary, comprising data from 769 participants, including 437 (57%) women. The available literature focused cardiac pain self-management from a binary sex and gender perspective. Ethnicity was indicated in 19 (54%) studies. Results support individualized intervention strategies that promote goal setting and action planning, management of physical and emotional responses, and social facilitation provided through social support.

The impact of therapeutic opioid agonists on driving-related psychomotor skills assessed by a driving simulator or an on-road driving task: A systematic review

BACKGROUND

Driving cessation is associated with poor health-related outcomes. People with chronic diseases are often prescribed long-term opioid agonists that have the potential to impair driving. Studies evaluating the impact of opioids on driving-related psychomotor skills report contradictory results likely due to heterogeneous designs, assessment tools and study populations. A better understanding of the effects of regular therapeutic opioid agonists on driving can help to inform the balance between individual's independence and community safety.

AIM

To identify the literature assessing the impact of regular therapeutic opioid agonists on driving-related psychomotor skills for people with chronic pain or chronic breathlessness.

DESIGN

Systematic review reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis statement; PROSPERO Registration CRD42017055909.

DATA SOURCES

Six electronic databases and grey literature were systematically searched up to January, 2017. Inclusion criteria were as follows: (1) empirical studies reporting data on driving simulation, on-the-road driving tasks or driving outcomes; (2) people with chronic pain or chronic breathlessness; and (3) taking regular therapeutic opioid agonists. Critical appraisal used the National Institutes of Health's quality assessment tools.

RESULTS

From 3809 records screened, three studies matched the inclusion criteria. All reported data on people with chronic non-malignant pain. No significant impact of regular therapeutic opioid agonists on people's driving-related psychomotor skills was reported. One study reported more intense pain significantly worsened driving performance.

CONCLUSION

This systematic review does not identify impaired simulated driving performance when people take regular therapeutic opioid agonists for symptom control, although more prospective studies are needed.

Chest pain and shortness of breath in cardiovascular disease: a prospective cohort study in UK primary care

OBJECTIVE

To determine characteristics associated with monthly chest pain and shortness of breath (SoB) during activity in cardiovascular disease (CVD) and trajectories of these symptoms over 10 months.

STUDY DESIGN AND SETTING

Baseline questionnaire was sent to patients aged ≥40 years from 10 UK general practices. Responders were sent monthly questionnaires for 10 months. For patients with CVD (ischaemic heart disease and heart failure), the association of sociodemographic characteristics, pain elsewhere and anxiety and depression with monthly reports of chest pain and SoB during activity were determined using multilevel, multinomial logistic regression. Common symptom trajectories were determined using dual trajectory latent class growth analysis.

RESULTS

661 patients with CVD completed at least 5 monthly questionnaires. Multiple other pain sites (relative risk ratio: 4.03; 95% CI 1.64 to 9.91) and anxiety or depression (relative risk ratio: 3.31; 95% CI 1.89 to 5.79) were associated with reporting weekly chest pain. Anxiety or depression (relative risk ratio: 4.10; 95% CI 2.72 to 6.17), obesity (relative risk ratio: 2.53; 95% CI 1.49 to 4.30), older age (80+: relative risk ratio: 2.51; 95% CI 1.19 to 5.26), increasing number of pain sites (4+: relative risk ratio: 4.64; 95% CI 2.35 to 9.18) and female gender (relative risk ratio: 1.81; 95% CI 1.20 to 2.75) were associated with reporting weekly SoB. Eight symptom trajectories were identified, with SoB symptoms more common than chest pain.

CONCLUSIONS

Potentially modifiable characteristics are associated with the experience of chest pain and SoB. Identified symptom trajectories may facilitate tailored care to improve outcomes in patients with CVD.

Symptom profiles and inflammatory markers in moderate to severe COPD

BACKGROUND

Physical and psychological symptoms are the hallmark of patients' subjective perception of their illness. The purpose of this analysis was to determine if patients with COPD have distinctive symptom profiles and to examine the association of symptom profiles with systemic biomarkers of inflammation.

METHODS

We conducted latent class analyses of three physical (dyspnea, fatigue, and pain) and two psychological symptoms (depression and anxiety) in 302 patients with moderate to severe COPD using baseline data from a longitudinal observational study of depression in COPD. Systemic inflammatory markers included IL1, IL8, IL10, IL12, IL13, INF, GM-CSF, TNF-α (levels >75^thcentile was considered high); and CRP (levels >3 mg/L was considered high). Multinominal logistic regression models were used to examine the association between symptom classes and inflammation while adjusting for key socio-demographic and disease characteristics.

RESULTS

We found that a 4-class model best fit the data: 1) low physical and psychological symptoms (26%, Low-Phys/Low-Psych), 2) low physical but moderate psychological symptoms (18%, Low-Phys/Mod Psych), 3) high physical but moderate psychological symptoms (25%, High-Phys/Mod Psych), and 4) high physical and psychological symptoms (30%, High-Phys/High Psych). Unadjusted analyses showed associations between symptom class with high levels of IL7, IL-8 (p ≤ .10) and CRP (p < .01). In the adjusted model, those with a high CRP level were less likely to be in the High-Phys/Mod-Psych class compared to the Low-Phys/Low-Psych (OR: 0.41, 95%CI 0.19, 0.90) and Low-Phys/Mod-Psych classes (OR: 0.35, 95%CI 0.16, 0.78); elevated CRP was associated with in increased odds of being in the High-Phys/High-Psych compared to the High-Phys/Mod-Psych class (OR: 2.22, 95%CI 1.08, 4.58). Younger age, having at least a college education, oxygen use and depression history were more prominent predictors of membership in the higher symptom classes.

CONCLUSIONS

Patients with COPD can be classified into four distinct symptom classes based on five commonly co-occurring physical and psychological symptoms. Systemic biomarkers of inflammation were not associated with symptom class. Additional work to test the reliability of these symptom classes, their biological drivers and their validity for prognostication and tailoring therapy in larger and more diverse samples is needed.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT01074515 .

Dyspnea in Community-Dwelling Older Persons: A Multifactorial Geriatric Health Condition

OBJECTIVES

To evaluate the associations between a broad array of cardiorespiratory and noncardiorespiratory impairments and dyspnea in older persons.

DESIGN

Cross-sectional.

SETTING

Cardiovascular Health Study.

PARTICIPANTS

Community-dwelling persons (N = 4,413; mean age 72.6, 57.1% female, 4.5% African American, 27.2% <high school education, 54.7% ever-smokers).

MEASUREMENTS

Dyspnea severity (moderate to severe defined as American Thoracic Society Grade ≥2) and several impairments, including those established using spirometry (forced expiratory volume in 1 second (FEV₁ )), maximal inspiratory pressure (respiratory muscle strength), echocardiography, ankle-brachial index, blood pressure, whole-body muscle mass (bioelectrical impedance), single chair stand (lower extremity function), grip strength, serum hemoglobin and creatinine, Center for Epidemiologic Studies Depression Scale (CES-D), Mini-Mental State Examination, medication use, and body mass index (BMI).

RESULTS

In a multivariable logistic regression model, impairments that had strong associations with moderate to severe dyspnea were FEV₁ less than the lower limit of normal (adjusted odds ratio (aOR) = 2.88, 95% confidence interval (CI) = 2.37-3.49), left ventricular ejection fraction less than 45% (aOR = 2.12, 95% CI = 1.43, 3.16), unable to perform a single chair stand (aOR = 2.10, 95% CI = 1.61-2.73), depressive symptoms (CES-D score ≥16; aOR = 2.02, 95% CI = 1.26-3.23), and obesity (BMI ≥30; aOR = 2.07, 95% CI = 1.67-2.55). Impairments with modest but still statistically significant associations with moderate to severe dyspnea included respiratory muscle weakness, diastolic cardiac dysfunction, grip weakness, anxiety symptoms, and use of cardiovascular and psychoactive medications (aORs = 1.31-1.71).

CONCLUSION

In community-dwelling older persons, several cardiorespiratory and noncardiorespiratory impairments were significantly associated with moderate to severe dyspnea, akin to a multifactorial geriatric health condition.

The presence of respiratory disorders in individuals with low back pain: A systematic review

BACKGROUND

Inspiratory muscles, such as the diaphragm, play a key role in both respiration and spinal control. Therefore, diaphragm dysfunctions are often related to low back pain (LBP). However, few is known on the association between the presence of LBP and the presence of respiratory disorders (RD).

OBJECTIVES

To perform a systematic review on the relation between RD and LBP.

STUDY DESIGN

Systematic review.

METHODS

Two reviewers searched on PubMed/MEDLINE for studies concerning LBP and RD, from 1950 up to January 2016. The search string consisted of the following key words: low back pain, dyspnea, respiratory problems, lung diseases, comorbidity, pulmonary disease, chronic obstructive, smoking, asthma, allergy, sinusitis, respiratory tract infection and hyperventilation. The aim was to evaluate a potential correlation, co-occurrence or causality between RD and LBP.

RESULTS

A total of 16 articles were included. A significant correlation between the presence of LBP and the presence of RD such as dyspnea, asthma, different forms of allergy, and respiratory infections was found. No correlation was found between Chronic Obstructive Pulmonary Disease (COPD) and LBP, and no articles were found on the correlation between hyperventilation and LBP.

CONCLUSIONS

This is the first study providing an overview of the literature on the relation between LBP and RD. Immunological, biomechanical, psychosocial and socio-economic factors might explain this correlation. Smoking is likely to contribute. Future studies must reveal the causative relationship.

LEVEL OF EVIDENCE

Therapy, level 2a.

Breathlessness During the Last Week of Life in Palliative Care: An Australian Prospective, Longitudinal Study

CONTEXT

Breathlessness is a major cause of suffering and distress, and little is known about the trajectory of breathlessness near death.

OBJECTIVES

To determine the trajectory and clinical-demographic factors associated with breathlessness in the last week of life in patients receiving specialist palliative care.

METHODS

This was a prospective, longitudinal cohort study using national data on specialist palliative care from the Australian Palliative Care Outcomes Collaboration. We included patients in the Australian Palliative Care Outcomes Collaboration who died between July 1, 2013 and June 30, 2014 with at least one measurement of breathlessness on a 0-10 numerical rating scale in the week before death. The trajectory and factors associated with breathlessness were analyzed using multivariate random-effects linear regression.

RESULTS

A total 12,778 patients from 87 services (33,404 data points) were analyzed. The average observed breathlessness was 2.1 points and remained constant over time. Thirty-five percent reported moderate to severe distress (numerical rating scale ≥4) at some time in their last week. Factors associated with higher breathlessness were younger age, male gender, cardiopulmonary involvement, concurrent fatigue, nausea, pain, sleeping problems, higher Australia-modified Karnofsky Performance Status, and clinical instability in the multivariate analysis. Respiratory failure showed the largest association (mean adjusted difference 3.1 points; 95% confidence interval, 2.8-3.4).

CONCLUSION

Although breathlessness has been reported to worsen in the last months, the mean severity remained stable in the final week of life. In specialized palliative care, one in three people experienced significant breathlessness especially in respiratory disease.

Prevalence of thoracic pain in patients with chronic obstructive pulmonary disease and relationship with patient characteristics: a cross-sectional observational study

BACKGROUND

Objectives of this study were to evaluate the prevalence of thoracic pain in patients with chronic obstructive pulmonary disease (COPD) and its relationship with Forced Expiratory Volume in the first second (FEV1), static hyperinflation, dyspnoea, functional exercise capacity, disease-specific health status, anxiety, and depression.

METHODS

This cross-sectional observational study included patients with COPD entering pulmonary rehabilitation. Participants underwent spirometry, plethysmography, and measurement of single breath diffusion capacity. Pain was assessed using a multidimensional, structured pain interview. In addition, dyspnoea severity (Modified Medical Research Council Dyspnoea Scale (mMRC)), functional exercise capacity (six-minute walking distance (6MWD)), disease-specific health status (COPD Assessment Test (CAT)), and symptoms of anxiety and depression (Hospital Anxiety Depression Scale (HADS)) were recorded.

RESULTS

55 of the included 67 participants reported chronic pain (82.1%). 53.7% had thoracic pain. After considering multiple comparisons, only younger age and worse CAT scores were related with the presence of thoracic pain (p = 0.01). There were no relationships between thoracic pain and FEV1, static lung hyperinflation, diffusion capacity, mMRC score, 6MWD, anxiety or depression.

CONCLUSION

Thoracic pain is highly prevalent in COPD patients and is related to impaired disease-specific health status, but there is no relationship with FEV1, static hyperinflation, dyspnoea severity or functional exercise capacity.